Wednesday, February 22, 2006

Newspaper hype versus clinical reality

A February 22 New York Times article entitled “Why Doctors So Often Get It Wrong” (registration required) deals with the problem of medical diagnostic error. Claiming that medicine suffers from a “misdiagnosis crisis” the article asks “How can this be happening? And how is it not a source of national outrage?”

We are told the story of a little girl who suffered consequences of delayed diagnosis. The New York Times piece states that the girl, diagnosed as chickenpox, actually turned out to have a flesh eating virus which her doctors failed to diagnose until her organs started shutting down. Hmmm----what’s a flesh eating virus anyway? Chickenpox is a virus. Did the doctors diagnose the wrong virus? A more accurate BBC report indicates that the girl actually had chickenpox complicated by necrotizing fasciitis, a bacterial infection.

With that little trifle out of the way let’s consider the article’s major premise about misdiagnosis. The article mentions autopsy data showing a 20% misdiagnosis rate, with JAMA as the source. Although the Times gives no citation, the JAMA article in question is probably this systematic review of autopsy-detected diagnostic errors. What the Times neglected to point out is that although the JAMA analysis found a 23.5% error rate, the rate of errors likely to have affected outcome was only 9%. Moreover, while the Times article claims that the error rate has not improved since the 1930’s the JAMA study found a continuous decline in the error rate between 1966 and 2002.

Although the Times article suggests that pay for performance and penalties for errors might solve the “crisis” the data suggest otherwise. Studies on Pay for Performance to date have failed to demonstrate improved quality. A spate of articles analyzing medical error indicates that promotion of a culture of blame by penalizing doctors for honest mistakes is counter productive.

The JAMA perspective is more nuanced: “However, it remains unclear to what extent clinically missed diagnoses represent errors per se, rather than acceptable limits of antemortem diagnosis in the face of atypical clinical presentations. In fact, because the vast majority of autopsy studies come from teaching hospitals, published autopsy series may be enriched for atypical cases.”

10 comments:

Anonymous
said...

Uh, the study DID show improved screening rates for cervical cancer (at least according to the abstract).

The point is that doctors are like everyone else--they respond to financial incentives. You give incentives for getting it right, you'll get more doctors getting it right. To me, that logic is inescapable.

Of course, doctors--as members of an economically self-protective guild--do have an interest in looking good in the eyes of their peers, especially those who give referrals. No doubt that gives them an incentive to get it right--even if the ones they kill, maime, and injure pay just as much as those they "cure." Nonetheless, this effect is probably secondary.

Uh, the study DID show improved screening rates for cervical cancer (at least according to the abstract).But are cancer screening rates (in generally not just pap smears) a good measurement? Do you want your doctor to honestly tell you how many people need to be screened for 10 years to save one life? And how many people have false alarms and need to have more invasive tests during the same period? In how many people this leads to an endless cycle of testing? Do you want your doctor to discuss overdiagnosis (not sure if this applies to pap smears but it surely does apply to some other tests)? Do you want your doctor to honestly tell you about expected individual benefit and possible risks of screening or do you want your doctor to sugar coat possible harms and overestimate the benefit? BTW n% in desease-specific mortality reduction may be true but it sounds much bigger than when absolute numbers are used. Just as lifetime risk of getting a desease sounds much scarier than 10-year risk of dying from it with/without screening.

With P4P paying more for higher screening rates there'll be more incentives for doctors to pressure patients to have tests (and 'fire' those who feel that for them personally benefits don't outweigh the risks) and to avoid any mention of any kind of risks.

There was a study in JAMA that many women who had hysterectomies continued to have pap smears. There is absolutely no reason for women to do that, yet their doctors 'forgot' to mention it to them. There is not much reason for 70+ year olds with no sex life and a history of normal pap smears to continue screening. Yet most of them don't know it. Even for many younger women the test can be done less often than every year. Yet, most doctors 'forget' to mention it.

Is this a good thing? Do we want doctors to pressure us to have tests or do we want honest information and choice? Because contrary to what most Americans are led to believe screening is not an obligation. It is a choice. Unfortunately in the US it is becoming a religion. Another thing. With time spent on pressuring somebody to get screened, the doctor will have less time to discuss stuff that is really important to this patient.

Also, a doctor that works in a poorer neighborhoods will most likely have worse screening rates. So his/her already lower pay will get even lower.

The bottom line in P4p is that patient choice is dependent on the psychological well being of the patient. I am a poor patient in that I do not go to a doctor unless I have tried every other trick in the book to get well. This means, I am a screening nightmare. I do not have routine screenings. I don't believe in them. I believe that if it isn't hurting, hanging out, or bleeding, it does not need fixing. Will I die of cancer one day. Maybe, but not from the toxic "cure" As a patient, I vote for choice in quality of life. No doctor will ever get financially well off treating me or testing me. But on the otherhand, if I really do get sick, the Doctor does not have to wade through a bunch of whooeee, to find out I am really sick. I do not present an arsenal of prescriptions and over the counter drugs to wade through the side effects of. I am a litigator's nightmare. My solution to poor care is to not go back, not sue the physician. I do not feel compelled to make an appointment on the vague notion that I am missing out on the fad disease of the week, month(heart disease February) or year- diabetes. I felt aches and pains one time that were not going away with the normal wait and see approach.(1980's) I was without testing or touching diagnosed with Chronic Fatigue Syndrome and a shrug of the shoulder. Weeks later a hidden dental infection was found to be the culprit.( I never had the fad disease at all and I never got checked so much as a stick out your tongue.) I never went back. P4P does work, if you are a conscientious consumer of services. IF you are a drugging looking for a pain killer, It will make the doctors look even better. The auditors would have a heck of a time keeping up with those darn narcotics seekers. I would imagine the new meaning of the Abreviation would really stand for Pay for Profits.

P4P does work, if you are a conscientious consumer of services. Unfortunately, there are lots of us who are in-between a conscientious consumer of services and somebody who tries to avoid doctors alltogether. Some people have chronic conditions and need to get refills. It may be a serious autoimmune condition or something trivial llike eczema and the only cream that works for them is not available OTC and they cannot go to the dermatologist without a referral. Others may want some screening tests but not others. With P4P every visit will turn into a doctor's going through a checklist that involves a bunch or recommended tests or screenings. This takes time and nerves. With P4P, every visit may cause more stress than necessary and become much longer than it should be.

Even worse, under P4P docs will be graded by how many of their patients have been taken down the checklist of approved/required screens. If you are "non-compliant," i.e., just don't feel like having that Pap done this year after 10 normal Paps and no sex for a decade, you may cost your doc money. He may decide that he doesn't want to be/can't afford to be your doc anymore. See ya later.